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APPLICATION FOR SANITATION PERMIT Permit No. _-_- (Complete in Duplicate) /l Date Issued -----�__�7._s` Applica*ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the wort ..herein described This application is made in compliance with County Ordinance No. 549. �f 5.- ' ' JOB ADDRESS AND LOCATION---- I --- -c------- --- 7...... _ ::?}1�----- ----- - Owner s Name--- .==' 4.-_ ---•. -,--'..:_z.__,_ 1._ --` - Phone �`� '_ _ _ ----- -------- - ---- Address-------------__---------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- Contractor's Name--- 2 ----- - - • - -- 5 --' � . Installation will serve: Residence 'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ ____ Number of bedrooms ---/-- Number of baths -1----- Lot size -----/----- ____--_.______________._ Water Supply: Public system ❑ Community system ❑ Private W4- Depth to Water Table _ :t ft. Character of soil to a depth of 3 feet: Sand hI - ravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No [�_--New Construction: Yes ❑ No U4-- TYPE 4- -,TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well__,5_a____Distance from foundation__._.!__�._-____.Material_____ -�.,a,_.___-_. No. of com artmenis________ ` p ,�-<,----.____Size--�--�---1�--`�-C�?--Liquid depth ---��---,�----�---Capacity-----�---�--`3---- Disposal Field: Distance from nearest well__S_L-._-__Distance from foundation------/_'---------Distance to nearest lot line___L __f____ 21, Number of lines--------------(____,_____ Length of each line--------- , ----------Width of trench_____ ? r_'______________ __•'J,._Depth of filter material____I_. '__�_'____Total length____ __C ----------------___________ Type of filter material____ �__A Seepage Pit: Distance to nearest well-------------.--------Distance from foundation--------------------Distance to nearest lot line-..-------------- El Number of pits______________________Lining material-----------------------Size: Diameter________----__-_.__Depth------------------------._______ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_-_____________________-_-______ ❑ Size: Diameter --------------Depth------ --------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------.-______________________________- ❑ Distance to nearest lot line----------------------------------------------•--------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):---------------------------------------------------------- -------------------------------------------------------------------.---- ------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sfafe law and ru� sand regulations of the San Joaquin Local Health District. (Signed) C. (Qwge#-aN�OF Contractor)--- BY• &+ ?� Z— --------�-x r f - ------ ------- ---- ------ -_ (Title) - •-` -------- ----- --------- h (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--•--b.----------------------------------- --------------------------------------------- DATE'> ----------------------------------------------- REVIEWEDBY-------------------------- ------- DATE_ ---------------------------------------------------- BUILDING ------------- - ----- ---- --------- ----------- ---------- ---------------- BUILDING PERMIT ISSUED---------------- ----------------------------------•-------------------------------------- DATE--------T)?,.,------------------------------------------------- Alt ra ons and/or recommendations: ------------------------- -it ----------------------------------------- --------- - .�c. - -pR_----------------- ----------- _ -------_tlr -_vs�•-s_ ___-____•__ __••_ _-_ __f__.__•_________________________ ______________••----------------------------•___ ----------•-__•--------------------------- ______ _ __________ ______ _ -_; � _.___.. ______.____------------.-------------.-------.-------------- ------ ------------------------------------------ ._--- _ _ .-___-.___-_-_____.__ FINAL INSPECTION BY: ------------- Date - --------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100